Management of severe acute malnutrition in low-income and middle-income countries

Common beans and cowpeas as complementary foods to reduce environmental enteric dysfunction and stunting in Malawian children: study protocol for two randomized controlled trials

Background

Interventions to decrease the burden of childhood malnutrition are urgently needed, as millions of children die annually owing to undernutrition and hundreds of millions more are left cognitively and physically stunted. Environmental enteric dysfunction (EED), a pervasive chronic subclinical inflammatory condition among children that develops when complementary foods are introduced, places them at high risk of stunting, malabsorption, and poor oral vaccine efficacy. Improved interventions to reduce the burden of EED and stunting are expected to markedly improve the nutritional status and survival of children throughout resource-limited settings.

Methods/Design

We will conduct, in parallel, two prospective randomized controlled clinical trials to determine whether common beans or cowpeas improve growth, ameliorate EED, and alter the intestinal microbiome during a high-risk period in the lives of rural Malawian children. Study 1 will enroll children at 6 months of age and randomize them to receive common beans, cowpeas, or a standard complementary food for 6 months. Anthropometry will be compared among the three groups; EED will be assessed using a dual-sugar absorption test and by quantifying human intestinal mRNA for inflammatory messages; and the intestinal microbiota will be characterized by deep sequencing of fecal DNA, to enumerate host microbial populations and their metabolic capacity. Study 2 will enroll children 12–23 months old and follow them for 12 months, with similar interventions and assessments as Study 1.

Discussion

By amalgamating the power of rigorous clinical trials and advanced biological analysis, we aim to elucidate the potential of two grain legumes to reduce stunting and EED in a high-risk population. Legumes have potential as an affordable and effective complementary food intervention, given their cultural acceptability, nutritional content, and agricultural feasibility in sub-Saharan Africa.

Trial registration

Clinicaltrials.gov NCT02472262 and NCT02472301.

Severe and Moderate Acute Malnutrition Can Be Successfully Managed with an Integrated Protocol in Sierra Leone

BACKGROUND

Global acute malnutrition (GAM) is the sum of moderate acute malnutrition (MAM) and severe acute malnutrition (SAM). The use of different foods and protocols for MAM and SAM treatment can be cumbersome in emergency settings.

OBJECTIVE

Our objective was to determine the recovery and coverage rates for GAM of an integrated protocol with a single food product, ready-to-use therapeutic food (RUTF), compared with standard management.

METHODS

This was a cluster-randomized controlled trial in Sierra Leone conducted in 10 centers treating GAM in children aged 6-59 mo. The integrated protocol used midupper arm circumference (MUAC) as the criterion for admission and discharge, with a MUAC <12.5 cm defining malnutrition. The protocol included a decreasing ration of RUTF and health maintenance messages delivered by peers. Standard therapy treated MAM with a fortified blended flour and SAM with RUTF and used weight-for-height to determine admission to the treatment program. Coverage rates were the number of children who received treatment/number of children in the community eligible for treatment.

RESULTS

Most of the children receiving integrated management had MAM (774 of 1100; 70%), whereas among those receiving standard management, SAM predominated (537 of 857; 63%; P = 0.0001). Coverage was 71% in the communities served by integrated management and 55% in the communities served by standard care (P = 0.0005). GAM recovery in the integrated management protocol was 910 of 1100 (83%) children and was 682 of 857 (79%) children in the standard therapy protocol.

CONCLUSION

Integrated management of GAM in children is an acceptable alternative to standard management and provides greater community coverage. This trial was registered at clinicaltrials.gov as NCT01785680.

[Effectiveness of a nutritional program based upon a ready-to-use therapeutic food in Chad]

OBJECTIVE

In the health district of Goundi in Chad, 6.7% of children were affected by acute malnutrition in 2011. The purpose of this study was to evaluate the efficacy of a locally made ready-to-use therapeutic food (RUTF).

METHODS

One hundred sixty-eight children were suffering from severe acute malnutrition (weight-for-height status less than -3 SD or mid-upper arm circumference less than 115mm). The RUTF was made in a specific laboratory. The product consisted of 49% carbohydrates, 33% lipids, 16% proteins, and 1.5% vitamins. Children received daily one packet of RUTF containing 500kcal as outpatient care.

RESULTS

At inclusion, the average age was 17.4±8.7 months, and the weight-for-height status -3.8±0.9 SD. At the end of the program, we noted recovery in 58.3% of the children, 2.4% unsuccessful treatment, 21.4% lost to follow-up, and 17.9% deaths (60% of which occurred during the first 2 weeks). At the end of the program, the weight-for-height status had increased by 2.1 SD. At recovery, children treated for tuberculosis had a higher weight-for-height status (-1.2±1.5 SD) than the children who were not infected by tuberculosis (-2±1.9 SD) (P<0.005).

CONCLUSION

Nutritional treatment using RUTF was effective. To improve treatment, early case detection should be improved, as should management of associated infectious diseases.

Gut DNA viromes of Malawian twins discordant for severe acute malnutrition

The bacterial component of the human gut microbiota undergoes a definable program of postnatal development. Evidence is accumulating that this program is disrupted in children with severe acute malnutrition (SAM) and that their persistent gut microbiota immaturity, which is not durably repaired with current ready-to-use therapeutic food (RUTF) interventions, is causally related to disease pathogenesis. To further characterize gut microbial community development in healthy versus malnourished infants/children, we performed a time-series metagenomic study of DNA isolated from virus-like particles (VLPs) recovered from fecal samples collected during the first 30 mo of postnatal life from eight pairs of mono- and dizygotic Malawian twins concordant for healthy growth and 12 twin pairs discordant for SAM. Both members of discordant pairs were sampled just before, during, and after treatment with a peanut-based RUTF. Using Random Forests and a dataset of 17,676 viral contigs assembled from shotgun sequencing reads of VLP DNAs, we identified viruses that distinguish different stages in the assembly of the gut microbiota in the concordant healthy twin pairs. This developmental program is impaired in both members of SAM discordant pairs and not repaired with RUTF. Phage plus members of the Anelloviridae and Circoviridae families of eukaryotic viruses discriminate discordant from concordant healthy pairs. These results disclose that apparently healthy cotwins in discordant pairs have viromes associated with, although not necessarily mediators, of SAM; as such, they provide a human model for delineating normal versus perturbed postnatal acquisition and retention of the gut microbiota's viral component in populations at risk for malnutrition.

Extending supplementary feeding for children younger than 5 years with moderate acute malnutrition leads to lower relapse rates

OBJECTIVES

Children with moderate acute malnutrition (MAM) have a high rate of relapse and death in the year following recovery. In this pilot study, we evaluate the long-term benefits of an extended course of nutritional therapy for children with MAM.

METHODS

Rural Malawian children 6 to 59 months old with MAM, defined as a weight-for-height z score (WHZ) between -2 and -3, were provided supplementary feeding for a fixed duration of 12 weeks. The children were then studied for 12 months to assess long-term nutritional status, and compared with children initially treated only until they first reached WHZ > -2.

RESULTS

Compared with children treated until they reached WHZ > -2, children treated for 12 weeks were more likely to remain well nourished (71% vs 63%, P = 0.0015) and maintain more normal anthropometric indices during 12 months of follow-up; there was also a trend towards lower rates of severe acute malnutrition (7% vs 10%, P = 0.067) and death (2% vs 4%, P = 0.082). Regression modeling showed that mid-upper arm circumference and WHZ at the end of supplementary feeding were the most important factors in predicting which children remained well nourished (P < 0.001 for each).

CONCLUSIONS

The duration of supplementary feeding for children with MAM may not be as important as their anthropometry in terms of remaining well nourished after initial recovery. The presently accepted recovery criteria of WHZ of -2 may be insufficient for ensuring long-term nutritional health; consideration should be given to setting higher recovery criteria.