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Bahwere P, Funnell G, Qarizada AN, Woodhead S, Bengnwi W, Le MT. 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. MATERNAL & CHILD NUTRITION 2024; 20:e13641. [PMID: 38627974 PMCID: PMC11168373 DOI: 10.1111/mcn.13641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 02/02/2024] [Accepted: 02/27/2024] [Indexed: 06/13/2024]
Abstract
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 treatment protocol (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-height z-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 the MTP 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 MUAC gain [∆ (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.
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Affiliation(s)
- Paluku Bahwere
- Center for Epidemiology, Biostatistics and Clinical Research (CR2), School of Public HealthUniversité Libre de BruxellesBrusselsBelgium
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Maru Y, Tamiru D, Baye K, Chitekwe S, Lailou A, Darsene H, Abdulai R, Worku M, Belachew T. Effect of a simplified approach on recovery of children 6-59 months with wasting in Ethiopia: A noninferiority, cluster randomized controlled trial. MATERNAL & CHILD NUTRITION 2024:e13670. [PMID: 38800892 DOI: 10.1111/mcn.13670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 05/29/2024]
Abstract
Worldwide, nearly 45 million children under the age of 5 years were affected by wasting in 2022. Ethiopia has been challenged by disasters increasing the caseload of children with wasting. This study aimed to determine the effect of a simplified approach on recovery of children with acute malnutrition as compared with the standard protocol. A cluster randomized, controlled, noninferiority trial was carried out in three regions of Ethiopia from December 4, 2021, to July 30, 2022. A total of 58 clusters (health posts) were randomized into intervention and control groups. Children with SAM in the intervention groups received two sachets of Ready-to-Use Therapeutic Food (RUTF), whereas children in the control groups received RUTF based on their body weight. Children with moderate acute malnutrition (MAM) received one sachet of RUTF and one sachet of Ready-to-Use Supplementary Food (RUSF) daily in the intervention and control groups, respectively. Per protocol (PP) and intention-to-treat analysis were used to compare recovery at a noninferiority margin of 15%. Data were collected from 55 health posts and 1032 children. In the PP analysis, the recovery rate of children with wasting among the simplified group (97.8%) was noninferior to the standard protocol group (97.7%), p = 0.399. The RUTF cost per treatment of child with SAM was 56.55 USD for the standard versus 42.78 USD for the simplified approach. The simplified approach is noninferior to the standard protocol in terms of recovery and has a lower cost of RUTF. Further study is recommended to assess the effectiveness of the simplified approach in emergency contexts.
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Affiliation(s)
- Yetayesh Maru
- Nutrition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| | - Dessalegn Tamiru
- Nutrition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| | - Kaleab Baye
- Center for Food Science and Nutrition, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Arnaud Lailou
- UNICEF West and Central Africa Regional Office, Nutrition Section, Dakar, Senegal
| | - Hiwot Darsene
- Nutrition Coordination Office, Ethiopian Ministry of Health, Addis Ababa, Ethiopia
| | - Rashid Abdulai
- Nutrition Section, UNICEF Ethiopia, Addis Ababa, Ethiopia
| | - Mesfin Worku
- Nutrition Section, UNICEF Ethiopia, Addis Ababa, Ethiopia
| | - Tefera Belachew
- Nutrition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
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Maru Y, Tamiru D, Baye K, Chitekwe S, Kifle YG, Lailou A, Belachew T. 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. Front Pediatr 2024; 12:1337370. [PMID: 38840802 PMCID: PMC11150620 DOI: 10.3389/fped.2024.1337370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 05/03/2024] [Indexed: 06/07/2024] Open
Abstract
Introduction 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. Methods 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. Results 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. Conclusion 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. Clinical Trial Registration https://pactr.samrc.ac.za/, Identifier (PACTR202202496481398).
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Affiliation(s)
- Yetayesh Maru
- Nurition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| | - Dessalegn Tamiru
- Nurition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| | - Kaleab Baye
- Center for Food Science and Nutrition, Addis Ababa University, Addis Ababa, Ethiopia
- Nutrition and Food Systems Division, Research Center for Inclusive Development in Africa (RIDA), Addis Ababa, Ethiopia
| | | | - Yehenew G. Kifle
- Department of Mathematics and Statistics, University of Maryland Baltimore County, Baltimore, MD, United States
| | - Arnaud Lailou
- Nutrition Section, UNICEF West and Central Africa Regional Office, Dakar, Senegal
| | - Tefera Belachew
- Nurition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
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López-Ejeda N, Charle-Cuéllar P, Samake S, Dougnon AO, Sánchez-Martínez LJ, Samake MN, Bagayoko A, Bunkembo M, Touré F, Vargas A, Guerrero S. Effectiveness of decentralizing outpatient acute malnutrition treatment with community health workers and a simplified combined protocol: a cluster randomized controlled trial in emergency settings of Mali. Front Public Health 2024; 12:1283148. [PMID: 38450139 PMCID: PMC10915236 DOI: 10.3389/fpubh.2024.1283148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 01/12/2024] [Indexed: 03/08/2024] Open
Abstract
Background Outpatient treatment of acute malnutrition is usually centralized in health centers and separated into different programs according to case severity. This complicates case detection, care delivery, and supply chain management, making it difficult for families to access treatment. This study assessed the impact of treating severe and moderate cases in the same program using a simplified protocol and decentralizing treatment outside health centers through community health workers (CHWs). Methods A three-armed cluster randomized controlled trial under a non-inferiority hypothesis was conducted in the Gao region of Mali involving 2,038 children between 6 and 59 months of age with non-complicated acute malnutrition. The control arm consisted of 549 children receiving standard treatment in health centers from nursing staff. The first intervention arm consisted of 800 children treated using the standard protocol with CHWs added as treatment providers. The second intervention arm consisted of 689 children treated by nurses and CHWs under the ComPAS simplified protocol, considering mid-upper arm circumference as the sole anthropometric criterion for admission and discharge and providing a fixed dose of therapeutic food for severe and moderate cases. Coverage was assessed through cross-sectional surveys using the sampling evaluation of access and coverage (SLEAC) methodology for a wide area involving several service delivery units. Results The recovery rates were 76.3% in the control group, 81.8% in the group that included CHWs with the standard protocol, and 92.9% in the group that applied the simplified protocol, confirming non-inferiority and revealing a significant risk difference among the groups. No significant differences were found in the time to recovery (6 weeks) or in anthropometric gain, whereas the therapeutic food expenditure was significantly lower with the simplified combined program in severe cases (43 sachets fewer than the control). In moderate cases, an average of 35 sachets of therapeutic food were used. With the simplified protocol, the CHWs had 6% discharge errors compared with 19% with the standard protocol. The treatment coverage increased significantly with the simplified combined program (SAM +42.5%, MAM +13.8%). Implications Implementing a simplified combined treatment program and adding CHWs as treatment providers can improve coverage while maintaining non-inferior effectiveness, reducing the expenditure on nutritional intrants, and ensuring the continuum of care for the most vulnerable children.
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Affiliation(s)
- Noemí López-Ejeda
- EPINUT Research Group (ref. 920325), Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | | | - Salimata Samake
- Nutrition and Health Department, Action Against Hunger, Bamako, Mali
| | | | - Luis Javier Sánchez-Martínez
- EPINUT Research Group (ref. 920325), Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | - Mahamadou N’tji Samake
- Nutrition Directorate of the General Directorate of Health and Public Hygiene, Ministry of Health, Bamako, Mali
| | - Aliou Bagayoko
- Nutrition Directorate of the General Directorate of Health and Public Hygiene, Ministry of Health, Bamako, Mali
| | - Magloire Bunkembo
- Nutrition and Health Department, Action Against Hunger, Bamako, Mali
| | - Fanta Touré
- West and Central Africa Regional Office, Action Against Hunger, Dakar, Senegal
| | - Antonio Vargas
- Nutrition and Health Department, Action Against Hunger, Madrid, Spain
| | - Saul Guerrero
- Child Nutrition and Development Office, UNICEF, New York, NY, United States
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Guesdon B, Faruqi MI, Siddiqui MI, Usman G, Ariser KN, Shah R, Amin F, Masoud M, Tagar QD, Tonon B, Lesieur E, Memon KN. Mid-upper arm circumference only protocol in Pakistan: missed opportunities for children suffering from severe acute malnutrition? A mixed-methods observational study. Public Health Nutr 2024; 27:e31. [PMID: 38197153 PMCID: PMC10830331 DOI: 10.1017/s1368980024000041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 12/27/2023] [Accepted: 01/04/2024] [Indexed: 01/11/2024]
Abstract
OBJECTIVE 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). DESIGN 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. SETTING Data were collected from October to December 2021 in Tando Allah Yar District, Sindh. SUBJECTS 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. RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Benjamin Guesdon
- Action Contre la Faim – France, 102 rue de Paris, 93100Montreuil, France
| | - Meena Iqbal Faruqi
- Action Contre la Faim – France, 102 rue de Paris, 93100Montreuil, France
| | | | - Gulzar Usman
- Liaquat University of Medical & Health Sciences, Jamshoro, Pakistan
| | | | - Rafaina Shah
- Liaquat University of Medical & Health Sciences, Jamshoro, Pakistan
| | - Fatima Amin
- Action Against Hunger – Pakistan, Islamabad, Pakistan
| | | | | | - Brigitte Tonon
- Action Contre la Faim – France, 102 rue de Paris, 93100Montreuil, France
| | - Elise Lesieur
- Action Contre la Faim – France, 102 rue de Paris, 93100Montreuil, France
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Sánchez-Martínez LJ, Charle-Cuéllar P, Gado AA, Dougnon AO, Sanoussi A, Ousmane N, Lazoumar RH, Toure F, Vargas A, Hernández CL, López-Ejeda N. Impact of a simplified treatment protocol for moderate acute malnutrition with a decentralized treatment approach in emergency settings of Niger. Front Nutr 2023; 10:1253545. [PMID: 38099186 PMCID: PMC10719846 DOI: 10.3389/fnut.2023.1253545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 11/14/2023] [Indexed: 12/17/2023] Open
Abstract
Introduction Of the 45.4 million children under five affected by acute malnutrition in the world, the majority (31.8 million) are affected by moderate acute malnutrition (MAM). Its treatment is particularly complex in emergency settings such as the Diffa region in Niger. This study aims to evaluate the effectiveness and coverage of a simplified treatment protocol with Community Health Workers (CHWs) as treatment providers. Methods This study is a non-randomized controlled trial. The control group (n = 181) received the standard protocol currently used in country, delivered by nursing staff only in health centres and health posts, while the intervention group (n = 483) received the simplified protocol which included nursing at health centres and CHWs at health post as treatment providers. Results The recovery rate was higher in the simplified protocol group (99.6% vs. 79.56%, p < 0.001) recording lower time to recover and higher anthropometric gain. Treatment coverage in the intervention group increased from 28.8% to 84.9% and reduced in the control group (25.3% to 13.6%). No differences were found in the recovery rate of children treated by CHWs and nursing staff. Conclusion The outcomes using the simplified protocol exceeded humanitarian requirements and demonstrated improvements compared to the standard protocol showing that the simplified protocol could be safely provided by CHWs in an emergency context. Further research in other contexts is needed to scale up this intervention.
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Affiliation(s)
- Luis Javier Sánchez-Martínez
- Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | | | | | | | - Atté Sanoussi
- Nutrition Direction, Ministry of Health, Niamey, Niger
| | | | | | - Fanta Toure
- Action Against Hunger, West and Central Africa Regional Office, Dakar, Senegal
| | | | - Candela Lucía Hernández
- Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | - Noemí López-Ejeda
- Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
- EPINUT Research Group (Ref. 920325), Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
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Tickell KD, Achieng C, Masheti M, Anyango M, Ndirangu A, Diakhate MM, Yoshioka E, Levin C, Rubin Means A, Choo EM, Ronen K, Unger JA, Richardson BA, Singa BO, McGrath CJ. Family MUAC supported by a two-way SMS platform for identifying children with wasting: the Mama Aweza randomised controlled trial. EClinicalMedicine 2023; 64:102218. [PMID: 37781159 PMCID: PMC10541484 DOI: 10.1016/j.eclinm.2023.102218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/22/2023] [Accepted: 09/01/2023] [Indexed: 10/03/2023] Open
Abstract
Background Effective methods of preventing and identifying childhood wasting are required to achieve global child health goals. Family mid-upper arm circumference (MUAC) programs train caregivers to screen their child for wasting with MUAC tapes. We assessed the effectiveness of a two-way short message service (SMS) platform (referred to as the Maternally Administered Malnutrition Monitoring System [MAMMS]) in western Kenya. Methods In this individual-level randomised controlled trial in two rural countries in western Kenya, children (aged 5-12 months) were randomly allocated (1:1) to receive either standard care (SOC) or MAMMS. Randomisation method was permuted-block randomisation with a block size of 10. Eligible participants were children attending maternal child health clinics in the two counties whom had a MUAC between 12.5 and 14.0 cm. The MAMMS group received two MUAC tapes and weekly SMS reminders to screen their child's MUAC. The SOC group received routine community health volunteer services and additional quarterly visits from the study team. The primary analysis used a cox proportional hazards model to compare SOC and MAMMS time-to-diagnosis of wasting (MUAC <12.5 cm) confirmed by a health professional during 6-months follow-up. Secondary outcomes were days from enrolment to treatment initiation among children with wasting, proportion of all children with wasting who were identified by the two approaches (treatment coverage), mean MUAC at treatment initiation, and duration of wasting treatment. This trial was registered on ClinicalTrials.gov, NCT03967015. Findings Between August 1, 2019 and January 31, 2022, 1200 children were enrolled, among whom the incidence of confirmed wasting was 37% lower in the MAMMS group (hazard ratio: 0.63, 95% CI: 0.42-0.94, p = 0.022). Among children with wasting, the median number of days-to-diagnosis was similar between study groups (MAMMS: 63 days [interquartile range (IQR): 23-92], SOC: 58 days [IQR: 22-94]). Treatment coverage in the MAMMS group was 83.3% (95% CI: 39.9-100.0) while coverage in the SOC group was 55.6% (95% CI: 22.3-88.9%, p = 0.300). Treatment duration and mean MUAC at treatment initiation were similar between groups. Interpretation Family MUAC supported by SMS was associated with a 37% reduction in wasting among young children. Empowering caregivers to monitor their child's nutritional status at home may prevent a substantial proportion of moderate wasting. Funding Thrasher Research Foundation and Pamela and Evan Fowler.
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Affiliation(s)
| | - Cathering Achieng
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Mary Masheti
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Maureen Anyango
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Agnes Ndirangu
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Emily Yoshioka
- Department of Global Health, University of Washington, Seattle, USA
| | - Carol Levin
- Department of Global Health, University of Washington, Seattle, USA
| | | | - Esther M. Choo
- Department of Global Health, University of Washington, Seattle, USA
| | - Keshet Ronen
- Department of Global Health, University of Washington, Seattle, USA
| | | | | | - Benson O. Singa
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
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Kitesa GY, Berhe TT, Tedla GW, Sahile AT, Abegaz KH, Shama AT. Time to recovery and its predictors among under five children in outpatient therapeutic feeding programme in Borena zone, Southern Ethiopia: a retrospective cohort study. BMJ Open 2023; 13:e077062. [PMID: 37709317 PMCID: PMC10503381 DOI: 10.1136/bmjopen-2023-077062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/30/2023] [Indexed: 09/16/2023] Open
Abstract
OBJECTIVES This study aimed to assess the time to recovery and its predictors among 6-59 months aged children treated at an outpatient therapeutic feeding programme in Borena zone. DESIGN A retrospective cohort study. SETTING Facility based; 23 treatment sites included in this study. PARTICIPANTS Among the cohorts of 601 children aged 6-59 months enrolled from July 2019 to June 2021, records of 590 children were selected using systematic random sampling. Transfers and incomplete records were excluded. PRIMARY AND SECONDARY OUTCOME MEASURES Time to recovery was a main outcome while its predictors were secondary outcomes. RESULTS The median recovery time was 49 days (95% CI=49 to 52) with a recovery rate of 79.8% (95% CI=76.4 to 83.0). Absence of comorbidity (adjusted HR, AHR=1.72, 95% CI=1.08 to 2.73), referral way by trained mothers on screening (AHR=1.91, 95% CI=1.25 to 2.91), new admission (AHR=1.59, 95% CI=1.05 to 2.41) and adequate Plumpy'Nut provision (AHR=2.10, 95% CI=1.72 to 2.56) were significantly associated with time to recovery. It is also found that being from a distance ≥30 min to treatment site lowers a chance of recovery by 27% (AHR=0.73, 95% CI=0.60 to 0.89). CONCLUSIONS The findings showed that a time to recovery was within an acceptable range. Incidence of recovery is enhanced with early case detection, proper management, nearby service, new admissions, provision of adequate Plumpy'Nut and enabling mothers to screen their own children for acute malnutrition. However, we did not observe a statistically significant association among breastfeeding status, type of health facility, wasting type, vaccination and routine medications. Service providers should improve adherence to treatment protocols, defaulter tracing, community outreach and timely case identification.
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Affiliation(s)
- Gutu Yonas Kitesa
- Department of Public Health Nutrition, Addis Ababa Medical and Business College, Addis Ababa, Ethiopia
| | - Trhas Tadesse Berhe
- Department of Public Health, Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia
- Department of Public Health, Frontieri Consult Plc, Addis Ababa, Ethiopia
| | | | | | - Kedir Hussein Abegaz
- Department of Public Health,Biostatistics and Health Informatics, Madda Walabu University, Robe 247, Ethiopia
- Department of Biostatistics, Faculty of Medicine, Near East University, Near East Avenue, Nicosia 99138, Turkey
| | - Adisu Tafari Shama
- Department of Public Health, Institute of Health Sciences, Wollega University, Nekemte, Ethiopia
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Papadopoulou E, Lim YC, Chin WY, Dwan K, Munabi-Babigumira S, Lewin S. Lay health workers in primary and community health care for maternal and child health: identification and treatment of wasting in children. Cochrane Database Syst Rev 2023; 8:CD015311. [PMID: 37646367 PMCID: PMC10467022 DOI: 10.1002/14651858.cd015311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND Since the early 2010s, there has been a push to enhance the capacity to effectively treat wasting in children through community-based service delivery models and thus reduce morbidity and mortality. OBJECTIVES To assess the effectiveness of identification and treatment of moderate and severe wasting in children aged five years or under by lay health workers working in the community compared with health providers working in health facilities. SEARCH METHODS We searched MEDLINE, CENTRAL, two other databases, and two ongoing trials registers to 24 September 2021. We also screened the reference lists of related systematic reviews and all included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-randomised studies in children aged five years or under with moderate wasting (defined as weight-for-height Z-score (WHZ) below -2 but no lower than ≥ -3, or mid-upper-arm circumference (MUAC) below 125 mm but no lower than 115 mm, and no nutritional oedema) or severe wasting (WHZ below -3 or MUAC below 115 mm or nutritional oedema). Eligible interventions were: • identification by lay health workers (LHWs) of children with wasting (intervention 1); • identification by LHWs of children with wasting and medical complications needing referral (intervention 2); and • identification by LHWs of children with wasting without medical complications needing referral (intervention 3). Eligible comparators were: • identification and treatment of wasting by health professionals such as nurses or doctors (at health facilities); and • identification and treatment of wasting by health facility-based teams, including health professionals and LHWs. DATA COLLECTION AND ANALYSIS Two review authors independently screened trials, extracted data and assessed risk of bias using the Cochrane risk of bias tool (RoB 2) and Cochrane Effective Practice and Organisation of Care (EPOC) guidelines. We used a random-effects model to meta-analyse data, producing risk ratios (RRs) for dichotomous outcomes in trials with individual allocation, adjusted RRs for dichotomous outcomes in trials with cluster allocation (using the generic inverse variance method in Review Manager 5), and mean differences (MDs) for continuous outcomes. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included two RCTs and five non-RCTs. Six studies were from African countries, and one was from Pakistan. Six studies included children with severe wasting, and one included children with moderate wasting. All studies offered home-based ready-to-use therapeutic food treatment and monitoring. Children received antibiotics in three studies, vitamins or micronutrients in three studies, and deworming treatment in two studies. In three studies, the comparison arm involved LHWs screening children for malnutrition and referring them to health facilities for diagnosis and treatment. All the non-randomised studies had a high overall risk of bias. Interventions 1 and 2 Identification and referral for treatment by LHWs, compared with treatment by health professionals following self-referral, may result in little or no difference in the percentage of children who recover from moderate or severe wasting (MD 1.00%, 95% confidence interval (CI) -2.53 to 4.53; 1 RCT, 29,475 households; low certainty). Intervention 3 Compared with treatment by health professionals following identification by LHWs, identification and treatment of severe wasting in children by LHWs: • may slightly reduce improvement from severe wasting (RR 0.93, 95% CI 0.86 to 0.99; 1 RCT, 789 participants; low certainty); • may slightly increase non-response to treatment (RR 1.44, 95% CI 1.04 to 2.01; 1 RCT, 789 participants; low certainty); • may result in little or no difference in the number of children with WHZ above -2 on discharge (RR 0.94, 95% CI 0.28 to 3.18; 1 RCT, 789 participants; low certainty); • probably results in little or no difference in the number of children with WHZ between -3 and -2 on discharge (RR 1.09, 95% CI 0.87 to 1.36; 1 RCT, 789 participants; moderate certainty); • probably results in little or no difference in the number of children with WHZ below -3 (severe wasting) on discharge (RR 1.23, 95% CI 0.75 to 2.04; 1 RCT, 789 participants; moderate certainty); • probably results in little or no difference in the number of children with MUAC equal to or greater than 115 mm on discharge (RR 0.99, 95% CI 0.93 to 1.06; 1 RCT, 789 participants; moderate certainty); • results in little or no difference in weight gain per day (mean weight gain 0.50 g/kg/day higher, 95% CI 1.74 lower to 2.74 higher; 1 RCT, 571 participants; high certainty); • probably has little or no effect on relapse of severe wasting (RR 1.03, 95% CI 0.69 to 1.54; 1 RCT, 649 participants; moderate certainty); • may have little or no effect on mortality among children with severe wasting (RR 0.46, 95% CI 0.04 to 5.98; 1 RCT, 829 participants; low certainty); • probably has little or no effect on the transfer of children with severe wasting to inpatient care (RR 3.71, 95% CI 0.36 to 38.23; 1 RCT, 829 participants; moderate certainty); and • probably has little or no effect on the default of children with severe wasting (RR 1.48, 95% CI 0.65 to 3.40; 1 RCT, 829 participants; moderate certainty). The evidence was very uncertain for total MUAC gain, MUAC gain per day, total weight gain, treatment coverage, and transfer to another LHW site or health facility. No studies examined sustained recovery, deterioration to severe wasting, appropriate identification of children with wasting or oedema, appropriate referral of children with moderate or severe wasting, adherence, or adverse effects and other harms. AUTHORS' CONCLUSIONS Identification and treatment of severe wasting in children who do not require inpatient care by LHWs, compared with treatment by health professionals, may lead to similar or slightly poorer outcomes. We found only two RCTs, and the evidence from non-randomised studies was of very low certainty for all outcomes due to serious risks of bias and imprecision. No studies included children aged under 6 months. Future studies must address these methodological issues.
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Affiliation(s)
| | | | - Weng Yee Chin
- Department of Family Medicine and Primary Care, The University of Hong Kong, Pokfulam, Hong Kong
| | - Kerry Dwan
- The Liverpool School of Tropical Medicine, Liverpool, UK
| | - Susan Munabi-Babigumira
- Norwegian Institute of Public Health, Oslo, Norway
- Department of Health and Functioning, Western Norway University of Applied Sciences, Bergen, Norway
| | - Simon Lewin
- Norwegian Institute of Public Health, Oslo, Norway
- Department of Health Sciences, Norwegian University of Science and Technology (NTNU), Ålesund, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
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10
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Phelan K, Seri B, Daures M, Yao C, Alitanou R, Aly AAM, Maidadji O, Sanoussi A, Mahamadou A, Cazes C, Moh R, Becquet R, Shepherd S. Treatment outcomes and associated factors for hospitalization of children treated for acute malnutrition under the OptiMA simplified protocol: a prospective observational cohort in rural Niger. Front Public Health 2023; 11:1199036. [PMID: 37475774 PMCID: PMC10354363 DOI: 10.3389/fpubh.2023.1199036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/14/2023] [Indexed: 07/22/2023] Open
Abstract
Introduction Globally, access to treatment for severe and moderate acute malnutrition is very low, in part because different protocols and products are used in separate programs. New approaches, defining acute malnutrition (AM) as mid-upper arm circumference (MUAC) < 125 mm or oedema, are being investigated to compare effectiveness to current programs. Optimizing Malnutrition treatment (OptiMA) is one such strategy that treats AM with one product - ready-to-use therapeutic food, or RUTF - at reduced dosage as the child improves. Methods This study aimed to determine whether OptiMA achieved effectiveness benchmarks established in the Nigerien National Nutrition protocol. A prospective cohort study of children in the rural Mirriah district evaluated outcomes among children 6-59 months with uncomplicated AM treated under OptiMA. In a parallel, unconnected program in one of the two trial sites, all non-malnourished children 6-23 months of age were provided small quantity lipid-based nutritional supplements (SQ-LNS). A multivariate logistic regression identified factors associated with hospitalization. Results From July-December 2019, 1,105 children were included for analysis. Prior to treatment, 39.3% of children received SQ-LNS. Recovery, non-response, and mortality rates were 82.3%, 12.6%, and 0.7%, respectively, and the hospitalization rate was 15.1%. Children who received SQ-LNS before an episode of AM were 43% less likely to be hospitalized (ORa=0.57; 0.39-0.85, p = 0.004). Discussion OptiMA had acceptable recovery compared to the Nigerien reference but non-response was high. Children who received SQ-LNS before treatment under OptiMA were less likely to be hospitalized, showing potential health benefits of combining simplified treatment protocols with food-based prevention in an area with a high burden of malnutrition such as rural Niger.
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Affiliation(s)
- Kevin Phelan
- The Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Benjamin Seri
- PRISME-CI ANRS|MIE Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Maguy Daures
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Cyrille Yao
- PRISME-CI ANRS|MIE Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Rodrigue Alitanou
- The Alliance for International Medical Action (ALIMA), Niamey, Niger
| | | | | | - Atté Sanoussi
- Ministry of Health, Nutrition Division, Niamey, Niger
| | - Aboubacar Mahamadou
- High-Commission of the Nigériens Nourrissent les Nigériens (3N) Initiative, Niamey, Niger
| | - Cécile Cazes
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Raoul Moh
- PRISME-CI ANRS|MIE Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
- Dermatology and Infectiology Pedagogical Unit, Training and Research Units in Medical Sciences, Abidjan, Côte d'Ivoire
| | - Renaud Becquet
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Susan Shepherd
- The Alliance for International Medical Action (ALIMA), Dakar, Senegal
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11
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Briend A, Myatt M, Berkley JA, Black RE, Boyd E, Garenne M, Lelijveld N, Isanaka S, McDonald CM, Mwangwome M, O’Brien KS, Schwinger C, Stobaugh H, Taneja S, West KP, Khara T. Prognostic value of different anthropometric indices over different measurement intervals to predict mortality in 6-59-month-old children. Public Health Nutr 2023; 26:1210-1221. [PMID: 36722310 PMCID: PMC10346023 DOI: 10.1017/s1368980023000149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 11/18/2022] [Accepted: 12/26/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare the prognostic value of mid-upper arm circumference (MUAC), weight-for-height Z-score (WHZ) and weight-for-age Z-score (WAZ) for predicting death over periods of 1, 3 and 6 months follow-up in children. DESIGN Pooled analysis of twelve prospective studies examining survival after anthropometric assessment. Sensitivity and false-positive ratios to predict death within 1, 3 and 6 months were compared for three individual anthropometric indices and their combinations. SETTING Community-based, prospective studies from twelve countries in Africa and Asia. PARTICIPANTS Children aged 6-59 months living in the study areas. RESULTS For all anthropometric indices, the receiver operating characteristic curves were higher for shorter than for longer durations of follow-up. Sensitivity was higher for death with 1-month follow-up compared with 6 months by 49 % (95 % CI (30, 69)) for MUAC < 115 mm (P < 0·001), 48 % (95 % CI (9·4, 87)) for WHZ < -3 (P < 0·01) and 28 % (95 % CI (7·6, 42)) for WAZ < -3 (P < 0·005). This was accompanied by an increase in false positives of only 3 % or less. For all durations of follow-up, WAZ < -3 identified more children who died and were not identified by WHZ < -3 or by MUAC < 115 mm, 120 mm or 125 mm, but the use of WAZ < -3 led to an increased false-positive ratio up to 16·4 % (95 % CI (12·0, 20·9)) compared with 3·5 % (95 % CI (0·4, 6·5)) for MUAC < 115 mm alone. CONCLUSIONS Frequent anthropometric measurements significantly improve the identification of malnourished children with a high risk of death without markedly increasing false positives. Combining two indices increases sensitivity but also increases false positives among children meeting case definitions.
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Affiliation(s)
- André Briend
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Rolighedsvej 30, DK-1958, Frederiksberg, Denmark
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Arvo building, Arvo Ylpön katu 34, FIN-33014Tampere, Finland
| | - Mark Myatt
- Brixton Health, Cilfach Greigiog, Fford Celynin, Llwyngwril, Gwynedd, UK
- Emergency Nutrition Network, Kidlington, OX, UK
| | - James A Berkley
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, University of Oxford, UK
| | - Robert E Black
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Erin Boyd
- USAID, Bureau for Humanitarian Assistance, Washington, DC, USA
- Tufts University, Boston, MA, USA
| | - Michel Garenne
- IRD, UMI Résiliences, Paris, France
- FERDI, Université d’Auvergne, Clermont-Ferrand, France
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Sheila Isanaka
- Department of Research, Epicentre, Paris, France
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Christine M McDonald
- Departments of Pediatrics, and Epidemiology and Biostatistics, University of California, San Francisco, Oakland, CA, USA
| | - Martha Mwangwome
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Kenya Medical Research Institute (KEMRI), Centre for Geographic Medicine Research-Coast (CGMRC), Kilifi, Kenya
| | - Kieran S O’Brien
- Department of Ophthalmology, University of California, Francis I. Proctor Foundation, San Francisco, CA, USA
| | - Catherine Schwinger
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Heather Stobaugh
- Tufts University, Boston, MA, USA
- Action Against Hunger USA, New York, NY, USA
| | - Sunita Taneja
- Center for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Keith P West
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Tanya Khara
- Emergency Nutrition Network, Kidlington, OX, UK
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12
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Teta I, Foudjo BUS, Nielsen JN, Oben J, Nguefack-Tsague G, Ntentie FR, Cakir V, Klemm R, Kang Y. Outcomes of a food voucher program and factors associated with the recovery rate of children with moderate acute malnutrition in Far North Cameroon. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2023; 42:37. [PMID: 37120648 PMCID: PMC10148527 DOI: 10.1186/s41043-023-00379-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 04/13/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Research 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. METHODS This 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. RESULTS The 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). CONCLUSION The 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.
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Affiliation(s)
- Ismael Teta
- Helen Keller Intl, Derrière Usine Bastos, 1771 Nv Rte Bastos, Yaoundé, Cameroon.
| | | | | | - Julius Oben
- Faculty of Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | | | | | | | | | - Yunhee Kang
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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13
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Charle-Cuéllar P, Lopez-Ejeda N, Aziz Gado A, Dougnon AO, Sanoussi A, Ousmane N, Hamidou Lazoumar R, Sánchez-Martínez LJ, Toure F, Vargas A, Guerrero S. Effectiveness and Coverage of Severe Acute Malnutrition Treatment with a Simplified Protocol in a Humanitarian Context in Diffa, Niger. Nutrients 2023; 15:nu15081975. [PMID: 37111194 PMCID: PMC10146545 DOI: 10.3390/nu15081975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/15/2023] [Accepted: 04/18/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND the aim of this study is to evaluate the effectiveness and coverage of a simplified protocol that is implemented in health centers (HCs) and health posts (HPs) for children who are suffering from severe acute malnutrition (SAM) in the humanitarian context of Diffa. METHODS We conducted a non-randomized community-controlled trial. The control group received outpatient treatment for SAM, without medical complications, at HCs and HPs with the standard protocol of community management of acute malnutrition (CMAM). Meanwhile, with respect to the intervention group, the children with SAM received treatment at the HCs and HPs through a simplified protocol wherein the mid-upper arm circumference (MUAC) and the presence of edema were used as the admission criteria, and the children with SAM were administered doses of fixed ready-to-use therapeutic food (RUTF). RESULTS A total of 508 children, who were all under 5 years and had SAM, were admitted into the study. The cured proportion was 87.4% in the control group versus 96.6% in the intervention group (p value = 0.001). There was no difference between the groups in the length of stay, which was 35 days, but the intervention group used a lower quantity of RUTF-70 sachets versus 90 sachets, per child cured. Coverage increases were observed in both groups. DISCUSSION the simplified protocol used at the HCs and HPs did not result in worse recovery and resulted in fewer discharge errors compared to the standard protocol.
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Affiliation(s)
| | - Noemi Lopez-Ejeda
- EPINUT Research Group (Ref. 920325), Unit of Physical Anthropology, Department of Biodiversity, Ecology, Faculty of Biological Sciences, and Evolution, Complutense University of Madrid, 28040 Madrid, Spain
| | | | | | - Atté Sanoussi
- Nutrition Direction, Ministry of Health, Niamey BP 623, Niger
| | - Nassirou Ousmane
- Centre de Recherche Médicale et Sanitaire (CERMES), Niamey BP 10887, Niger
| | | | - Luis Javier Sánchez-Martínez
- EPINUT Research Group (Ref. 920325), Unit of Physical Anthropology, Department of Biodiversity, Ecology, Faculty of Biological Sciences, and Evolution, Complutense University of Madrid, 28040 Madrid, Spain
| | - Fanta Toure
- Action against Hunger, West and Central Africa Regional, Dakar BP 29621, Senegal
| | - Antonio Vargas
- Action against Hunger, C/Duque de Sevilla no. 3, 28002 Madrid, Spain
| | - Saul Guerrero
- United Nations International Children's Emergency Fund-UNICEF, 3 United Nations Plaza, New York, NY 10017, USA
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14
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Cazes C, Phelan K, Hubert V, Boubacar H, Bozama LI, Sakubu GT, Senge BB, Baya N, Alitanou R, Kouamé A, Yao C, Gabillard D, Daures M, Augier A, Anglaret X, Kinda M, Shepherd S, Becquet R. Optimising the dosage of ready-to-use therapeutic food in children with uncomplicated severe acute malnutrition in the Democratic Republic of the Congo: a non-inferiority, randomised controlled trial. EClinicalMedicine 2023; 58:101878. [PMID: 36915287 PMCID: PMC10006445 DOI: 10.1016/j.eclinm.2023.101878] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/24/2023] [Accepted: 02/03/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Current standard management of severe acute malnutrition uses ready-to-use therapeutic food (RUTF) at a single weight-based calculation resulting in an increasing amount of RUTF provided to the family as the child's weight increases during recovery. Using RUTF at a gradually reduced dosage as the child recovers could reduce costs while achieving similar growth response. METHODS We conducted an open-label, non-inferiority, randomised controlled trial in the Democratic Republic of the Congo. Children aged 6-59 months with a mid-upper-arm circumference (MUAC) of less than 115 mm or a weight-for-height z-score (WHZ) of less than -3 or bipedal oedema and without medical complication were randomly assigned (1:1 ratio) using a specially developed software and random blocks (size was kept confidential), to either the current standard treatment (increasing the RUTF amount with increasing weight) or the OptiMA strategy (decreasing the RUTF dose with increasing weight and MUAC). The main endpoint was proportion of children who achieved recovery over the 6 months follow up period, as defined as meeting the following criteria for two consecutive weeks after a minimum of 4 weeks' treatment: axillary temperature less than 37.5 °C, no bipedal oedema, and anthropometric improvement (either MUAC 125 mm or greater or WHZ -1.5 or higher). We performed analyses on the intention-to-treat (ITT) (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, and had a maximum interval of 6 weeks between any two visits in the 6-month follow-up). The non-inferiority margin was 10%. This trial is registered at ClinicalTrials.gov, and is now closed NCT03751475. FINDINGS Between July 22, 2019, and January 20, 2020, 491 children were randomly assigned, of whom 482 were analysed (240 in the standard group and 242 in the OptiMA group). In the ITT analysis, 234 (98%) children in the standard group and 231 (96%) children in OptiMA recovered (difference 2.0%, 95% CI -2.0% to 6.4%). In the PP analysis, 234 (98%) children in the standard group and 228 (97%) in OptiMA recovered (difference 1.3%, 95% CI -2.3% to 5.1%). Sensitivity analyses applying the same anthropometric recovery criteria to each group also showed non-inferiority of the OptiMA strategy in ITT and PP analysis. INTERPRETATION This non-inferiority trial treating uncomplicated children with MUAC of less than 115 mm or a WHZ of less than -3 or bipedal oedema with decreasing RUTF dose as MUAC and weight increase demonstrated non-inferiority compared to the standard protocol in a highly food-insecure context in the Democratic Republic of the Congo. These findings add evidence on the safety of RUTF dose reduction with significant RUTF cost savings. FUNDING Innocent Foundation and European Civil Protection and Humanitarian Aid Operations. TRANSLATION For the French translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Cécile Cazes
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Kevin Phelan
- The Alliance for International Medical Action (ALIMA), Paris, France
| | - Victoire Hubert
- The Alliance for International Medical Action (ALIMA), Kamuesha, Democratic Republic of the Congo
| | - Harouna Boubacar
- The Alliance for International Medical Action (ALIMA), Kamuesha, Democratic Republic of the Congo
| | - Liévin Izie Bozama
- National Nutrition Programme (PRONANUT), Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Gilbert Tshibangu Sakubu
- Kamuesha Health Zone in the Kasaï Province, Ministry of Health, Kamuesha, Democratic Republic of the Congo
| | - Bruno Bindamba Senge
- National Nutrition Programme (PRONANUT), Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Norbert Baya
- National Nutrition Programme (PRONANUT), Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Rodrigue Alitanou
- The Alliance for International Medical Action (ALIMA), Kamuesha, Democratic Republic of the Congo
| | - Antoine Kouamé
- PACCI ANRS Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Cyrille Yao
- PACCI ANRS Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Delphine Gabillard
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Maguy Daures
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Augustin Augier
- The Alliance for International Medical Action (ALIMA), Paris, France
| | - Xavier Anglaret
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Moumouni Kinda
- The Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Susan Shepherd
- The Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Renaud Becquet
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
- Corresponding author. Bordeaux Population Health Centre, Team GHiGS, University of Bordeaux, Bordeaux 33076, France.
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15
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Effectiveness of Acute Malnutrition Treatment at Health Center and Community Levels with a Simplified, Combined Protocol in Mali: An Observational Cohort Study. Nutrients 2022; 14:nu14224923. [PMID: 36432609 PMCID: PMC9699530 DOI: 10.3390/nu14224923] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/02/2022] [Accepted: 11/07/2022] [Indexed: 11/22/2022] Open
Abstract
A simplified, combined protocol was created that admits children with a mid-upper-arm circumference (MUAC) of <125 mm or edema to malnutrition treatment with ready-to-use therapeutic food (RUTF) that involves prescribing two daily RUTF sachets to children with MUAC < 115 mm or edema and one daily sachet to those with 115 mm ≤ MUAC < 125 mm. This treatment was previously shown to result in non-inferior programmatic outcomes compared with standard treatment. We aimed at observing its effectiveness in a routine setting at scale, including via delivery by community health workers (CHWs). A total of 27,800 children were admitted to the simplified, combined treatment. Treatment resulted in a 92% overall recovery, with a mean length of stay of 40 days and a mean RUTF consumption of 62 sachets per child treated. Among children admitted with MUAC < 115 mm or edema, 87% recovered with a mean length of stay of 55 days and consuming an average of 96 RUTF sachets. The recovery in all sub-groups studied exceeded 85%. Treatment by CHWs resulted in a similar (94%) recovery to treatment by formal healthcare workers (92%). The simplified, combined protocol resulted in high recovery and low RUTF consumption per child treated and can safely be adopted by CHWs to provide treatment at the community level.
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Wrabel M, Stokes‐Walters R, King S, Funnell G, Stobaugh H. Programmatic adaptations to acute malnutrition screening and treatment during the COVID‐19 pandemic. MATERNAL & CHILD NUTRITION 2022; 18:e13406. [PMID: 35929509 PMCID: PMC9480950 DOI: 10.1111/mcn.13406] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/13/2022] [Accepted: 06/21/2022] [Indexed: 11/30/2022]
Abstract
The COVID‐19 pandemic presented numerous challenges to acute malnutrition screening and treatment. To enable continued case identification and service delivery while minimising transmission risks, many organisations and governments implemented adaptations to community‐based management of acute malnutrition (CMAM) programmes for children under 5. These included: Family mid‐upper arm circumference (MUAC); modified admission and discharge criteria; modified dosage of therapeutic foods; and reduced frequency of follow‐up visits. This paper presents qualitative findings from a larger mixed methods study to document practitioners' operational experiences and lessons learned from these adaptations. Findings reflect insights from 37 interviews representing 15 organisations in 17 countries, conducted between July 2020 and January 2021. Overall, interviewees indicated that adaptations were mostly well‐accepted by staff, caregivers and communities. Family MUAC filled screening gaps linked to COVID‐19 disruptions; however, challenges included long‐term accuracy of caregiver measurements; implementing an intervention that could increase demand for inconsistent services; and limited guidance to monitor programme quality and impact. Modified admission and discharge criteria and modified dosage streamlined logistics and implementation with positive impacts on staff workload and caregiver understanding of the programme. Reduced frequency of visits enabled social distancing by minimising crowding at facilities and lessened caregivers' need to travel. Concerns remained about how adaptations impacted children's identification for and progress through treatment and programme outcomes. Most respondents anticipated reverting to standard protocols once transmission risks were mitigated. Further evidence, including multi‐year programmatic data analysis and rigorous research, is needed in diverse contexts to understand adaptations' impacts, including how to ensure equity and mitigate unintended consequences. COVID‐19 CMAM programme adaptations enabled service continuity despite pandemic‐related challenges. Further evidence is needed on long‐term impacts. Family MUAC was well‐accepted and addressed screening gaps from COVID‐19 disruptions. Challenges included sustaining caregiver measurement accuracy; handling inaccurate self‐referrals to encourage health‐seeking behaviours; and limited programme design and monitoring guidance and tools. Modified admission criteria and therapeutic food dosage reduced contact between staff and children and streamlined logistics and implementation. Concerns remained about effects on programme admissions and outcomes. Reduced frequency of follow‐up visits successfully reduced facility crowding and need for caregiver travel. However, infrequent monitoring of childrenmay miss deterioration.
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Affiliation(s)
| | | | - Sarah King
- Action Against Hunger USA Washington, DC USA
| | | | - Heather Stobaugh
- Action Against Hunger USA Washington, DC USA
- Friedman School of Nutrition Science and Policy Tufts University Boston Massachusetts USA
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17
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The OptiMA protocol in children with wasting and stunting. Lancet Glob Health 2022; 10:e957. [DOI: 10.1016/s2214-109x(22)00247-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/16/2022] [Indexed: 11/21/2022]
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18
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Owusu SM, Chen J, Merz E, Fu C. Progressing towards nutritional health in Sub‐Saharan Africa: An econometric analysis of the effect of sustainable food production on malnutrition. Int J Health Plann Manage 2022; 37:2266-2283. [DOI: 10.1002/hpm.3468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 01/05/2022] [Accepted: 03/21/2022] [Indexed: 11/08/2022] Open
Affiliation(s)
| | - Jianlin Chen
- School of Business Jinggangshan University Ji'an Jiangxi China
| | - Ellen Merz
- School of Business Jinggangshan University Ji'an Jiangxi China
| | - Chuanbo Fu
- School of Business Jinggangshan University Ji'an Jiangxi China
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19
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Sato R, Daures M, Phelan K, Shepherd S, Kinda M, Becquet R, Hecht R, Resch S. Utilization patterns, outcomes and costs of a simplified acute malnutrition treatment programme in Burkina Faso. MATERNAL & CHILD NUTRITION 2022; 18:e13291. [PMID: 34957682 PMCID: PMC8932691 DOI: 10.1111/mcn.13291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 12/01/2022]
Abstract
Access to treatment for acute malnutrition remains a challenge, in part due to the fragmentation of treatment programmes based on case severity. This paper evaluates utilization patterns, outcomes and associated costs for treating acute malnutrition cases among a cohort of children in Burkina Faso. This study is a secondary analysis of a proof‐of‐concept trial, called Optimizing treatment for acute Malnutrition (OptiMA), conducted in Burkina Faso in 2016. A total of 4958 eligible children whose mid‐upper arm circumference (MUAC) was less than 125 mm or with oedema were followed weekly and given ready‐to‐use therapeutic foods (RUTF). We evaluated the service utilization and outcomes among patients and estimated resource use and variable cost per patient, and examined factors driving variation in resource use. Children with lower initial MUAC level grew faster but required more time to recover than those with higher initial MUAC level. They also had higher rates of death, default and nonresponse. The simplified OptiMA approach for treating acute malnutrition achieved high rates of recovery overall (84%), especially among less severe cases, with modest quantities of RUTF. The average overall variable cost per child admitted was US$38.0 (SD: 20.5) half of which was accounted for by the cost of RUTF. Cost per recovered case was correlated with case severity, ranging from US$35.1 to US$132.8. If simplified integrated programmes using severity‐based RUTF dosing can increase access to treatment at earlier, less severe stages of acute malnutrition, they can help avoid more serious and costlier cases. This paper evaluates utilization patterns, outcomes, and associated costs for treating acute malnutrition cases among a cohort of children in Burkina Faso. Children with lower initial mid upper arm circumference (MUAC) level grew faster but required more time to recover than those with higher initial MUAC level. The average cost per child admitted was US$38.0 half of which was accounted for by the cost of ready to use therapeutic foods (RUTF). If simplified programs can increase access to treatment at earlier, less severe stages of acute malnutrition, they can help avoid more serious and costlier cases.
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Affiliation(s)
- Ryoko Sato
- Harvard T. H. Chan School of Public Health Boston Massachusetts USA
| | - Maguy Daures
- Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center University of Bordeaux Bordeaux France
| | - Kevin Phelan
- The Alliance for International Medical Action (ALIMA) Paris France
| | - Susan Shepherd
- The Alliance for International Medical Action (ALIMA) Paris France
| | - Moumouni Kinda
- The Alliance for International Medical Action (ALIMA) Paris France
| | - Renaud Becquet
- Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center University of Bordeaux Bordeaux France
| | | | - Stephen Resch
- Harvard T. H. Chan School of Public Health Boston Massachusetts USA
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20
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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. THE LANCET GLOBAL HEALTH 2022; 10:e510-e520. [DOI: 10.1016/s2214-109x(22)00041-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/22/2021] [Accepted: 01/24/2022] [Indexed: 12/20/2022] Open
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21
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Daures M, Hien J, Phelan K, Boubacar H, Atté S, Aboubacar M, Aly AAGM, Mayoum B, Azani JC, Koffi JJ, Séri B, Beuscart A, Gabillard D, Hubert V, Cazes C, Kinda M, Anglaret X, Kangas S, Shepherd S, Becquet R. Simplifying and optimising management of acute malnutrition in children aged 6 to 59 months: study protocol for a 3 arms community-based individually randomised controlled trial in decentralised Niger. Trials 2022; 23:89. [PMID: 35090531 PMCID: PMC8796195 DOI: 10.1186/s13063-021-05955-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Simplified approaches of acute malnutrition (AM) treatment have been conducted over the past 5 years intending to unify processes and increase coverage among children aged 6 to 59 months without medical complication. The Optimsing treatment for Acute Malnutrition (OptiMA) and the Combined Protocol for Acute Malnutrition Study (ComPAS) are mid-upper arm circumference (MUAC)-based approaches treating children with MUAC < 125 mm or oedema with one sole product-ready-to-use therapeutic food-at a gradually tapered doses. This trial aims to compare the OptiMA and ComPAS strategies to the standard nutritional protocol of Niger assessed by a favourable outcome in the treatment of uncomplicated AM at 6 months post-randomisation and in terms of recovery rate after treatment of uncomplicated SAM (WHZ < - 3 or MUAC < 115mm or oedema) and among the most vulnerable children (MUAC < 115mm or oedema). METHODS A non-inferiority individually randomised controlled clinical trial was conducted at the primary health centres level and in the community in the Zinder region in Niger in March 2021. Participants are children aged 6-59 months attending outpatient health centres with MUAC < 125mm or oedema without medical complications. All participants are followed for 6 months. Simplified strategies propose a gradual reduction of RUTF according to MUAC and weight in OptiMA and MUAC only in ComPAS. Favourable outcome is compositely defined at 6 months post-inclusion as being alive, not acutely malnourished by the definition applied at inclusion and without any additional episode of AM throughout the 6-month observation period. Recovery is defined throughout the 6 months post-randomisation by a minimum of 4-week duration of treatment, an axillary temperature < 37.5°C, an absence of bipedal oedema and a MUAC ≥ 125 mm for two consecutive weeks. The sample size calculation required 567 children per arm for the main objective, 295 and 384 children per arm for the secondary objectives among SAM and MUAC < 115 mm children, respectively. Per-protocol and intention-to-treat analyses will be conducted for each outcome. DISCUSSION This trial is intending to generate much-needed evidence on various simplified and optimised AM treatment approaches and to participate in reaching a consensus on such nutrition protocols. TRIAL REGISTRATION ClinicalTrials.gov NCT04698070 . Registered on January 6, 2021.
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Affiliation(s)
- Maguy Daures
- Fench National Institute for Health and Medical Research (Inserm), French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, University of Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France.
| | - Jérémie Hien
- The Alliance for International Medical Action (ALIMA), Zinder, Niger
| | - Kevin Phelan
- The Alliance for International Medical Action (ALIMA), Paris, France
| | - Harouna Boubacar
- The Alliance for International Medical Action (ALIMA), Zinder, Niger
| | - Sanoussi Atté
- Nutrition Directorate, Ministry of Health, Niamey, Niger
| | - Mahamadou Aboubacar
- Commission for the Initiative "les Nigériens Nourrissent les Nigériens" (HC3N), Niamey, Niger
| | - Ahmad A G M Aly
- The Alliance for International Medical Action (ALIMA), Zinder, Niger
| | - Baweye Mayoum
- The Alliance for International Medical Action (ALIMA), 15 rue des immeubles industriels, 75011, Dakar, Senegal
| | - Jean-Claude Azani
- PACCI Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Jean-Jacques Koffi
- PACCI Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Benjamin Séri
- PACCI Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Aurélie Beuscart
- Fench National Institute for Health and Medical Research (Inserm), French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, University of Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France
| | - Delphine Gabillard
- Fench National Institute for Health and Medical Research (Inserm), French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, University of Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France
| | - Victoire Hubert
- The Alliance for International Medical Action (ALIMA), 15 rue des immeubles industriels, 75011, Dakar, Senegal
| | - Cécile Cazes
- Fench National Institute for Health and Medical Research (Inserm), French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, University of Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France
| | - Moumouni Kinda
- The Alliance for International Medical Action (ALIMA), 15 rue des immeubles industriels, 75011, Dakar, Senegal.
| | - Xavier Anglaret
- Fench National Institute for Health and Medical Research (Inserm), French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, University of Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France
| | - Suvi Kangas
- International Rescue Committee (IRC), Dakar, Senegal
| | - Susan Shepherd
- The Alliance for International Medical Action (ALIMA), 15 rue des immeubles industriels, 75011, Dakar, Senegal
| | - Renaud Becquet
- Fench National Institute for Health and Medical Research (Inserm), French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, University of Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France
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22
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Lelijveld N, Godbout C, Krietemeyer D, Los A, Wegner D, Hendrixson DT, Bandsma R, Koroma A, Manary M. Treating high-risk moderate acute malnutrition using therapeutic food compared with nutrition counseling (Hi-MAM Study): a cluster-randomized controlled trial. Am J Clin Nutr 2021; 114:955-964. [PMID: 33963734 PMCID: PMC8921644 DOI: 10.1093/ajcn/nqab137] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 04/01/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND There is a lack of consensus on what is the most appropriate treatment of moderate acute malnutrition (MAM). OBJECTIVES We 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. METHODS At 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. RESULTS Analysis 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. CONCLUSIONS Provision 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.
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Affiliation(s)
| | - Claire Godbout
- Project Peanut Butter, Freetown, Sierra
Leone,Washington University School of Medicine, St. Louis, MO,
USA
| | - Destiny Krietemeyer
- Project Peanut Butter, Freetown, Sierra
Leone,Washington University School of Medicine, St. Louis, MO,
USA
| | - Alyssa Los
- Project Peanut Butter, Freetown, Sierra
Leone,Washington University School of Medicine, St. Louis, MO,
USA
| | - Donna Wegner
- Washington University School of Medicine, St. Louis, MO,
USA
| | | | - Robert Bandsma
- Centre for Global Child Health, Hospital for Sick Kids,
Toronto, Ontario, Canada
| | | | - Mark Manary
- Project Peanut Butter, Freetown, Sierra
Leone,Washington University School of Medicine, St. Louis, MO,
USA
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23
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Incidence of relapse following a new approach to simplifying and optimising acute malnutrition treatment in children aged 6-59 months: a prospective cohort in rural Northern Burkina Faso. J Nutr Sci 2021; 10:e27. [PMID: 33996040 PMCID: PMC8080230 DOI: 10.1017/jns.2021.18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 01/22/2023] Open
Abstract
The present study aimed to determine the 3-month incidence of relapse and associated factors among children who recovered under the Optimising treatment for acute MAlnutrition (OptiMA) strategy, a MUAC-based protocol. A prospective cohort of children successfully treated for acute malnutrition was monitored between April 2017 and February 2018. Children were seen at home by community health workers (CHWs) every 2 weeks for 3 months. Relapse was defined as a child who had met OptiMA recovery criteria (MUAC ≥ 125 mm for two consecutive weeks) but subsequently had a MUAC < 125 mm at any home visit. Cumulative incidence and incidence rates per 100 child-months were estimated. Multivariable survival analysis was conducted using a shared frailty model with a random effect on health facilities to identify associated factors. Of the 640 children included, the overall 3-month cumulative incidence of relapse was 6⋅8 % (95 % CI 5⋅2, 8⋅8). Globally, the incidence rate of relapse was 2⋅5 (95 % CI 1⋅9, 3⋅3) per 100 child-months and 3⋅7 (95 % CI 1⋅9, 6⋅8) per 100 child-months among children admitted with a MUAC < 115 mm. Most (88⋅6 %) relapses were detected early when MUAC was between 120 and 124 mm. Relapse was positively associated with hospitalisation, with an adjusted hazard ratio (aHR) of 2⋅06 (95 % CI 1⋅01, 4⋅26) for children who had an inpatient stay at any point during treatment compared with children who did not. The incidence of relapse following recovery under OptiMA was relatively low in this context, but the lack of a standard relapse definition does not allow for comparison across settings Closer follow-up with caretakers whose children are admitted with MUAC < 115 mm or required hospitalisation during treatment should be considered in managing groups at high risk of relapse. Training caretakers to screen their children for relapse at home using MUAC could be more effective at detecting early relapse, and less costly, than home visits by CHWs.
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Key Words
- AM, acute malnutrition
- Acute malnutrition
- CHWs, community health workers
- CIs, confidence intervals
- CORTASAM, Council of Research & Technical Advice on Acute Malnutrition
- Children
- HAZ, height-for-age Z-score
- IQR, interquartile range
- Incidence
- MAM, moderate acute malnutrition
- MUAC, mid-upper arm circumference
- MUAC-based and reduced doses protocol
- OptiMA, Optimising treatment for acute MAlnutrition
- RDT, rapid diagnostic tests
- RUTF, ready-to-use therapeutic food
- Relapse
- SAM, severe acute malnutrition
- WHO, World Health Organization
- WHZ, weight-for-height Z-score
- West Africa
- aHR, adjusted hazard ratio
- sd, standard deviation
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Schaefer R, Mayberry A, Briend A, Manary M, Walker P, Stobaugh H, Hanson K, McGrath M, Black R. Relapse and regression to severe wasting in children under 5 years: A theoretical framework. MATERNAL & CHILD NUTRITION 2021; 17:e13107. [PMID: 33145990 PMCID: PMC7988852 DOI: 10.1111/mcn.13107] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/04/2020] [Accepted: 10/15/2020] [Indexed: 12/21/2022]
Abstract
Systematic reviews have highlighted that repeated severe wasting after receiving treatment is likely to be common, but standardised measurement is needed urgently. The Council of Research & Technical Advice for Acute Malnutrition (CORTASAM) released recommendations on standard measurement of relapse (wasting within 6 months after exiting treatment as per recommended discharge criteria), regression (wasting within 6 months after exiting treatment before reaching recommended discharge criteria) and reoccurrence (wasting after 6 months of exit from treatment as per recommended discharge criteria). We provide a theoretical framework of post-treatment relapse and regression to severe wasting to guide discussions, risk factor analyses, and development and evaluations of interventions. This framework highlights that there are factors that may impact risk of relapse and regression in addition to the impact of contextual factors associated with incidence and reoccurrence of severe wasting more generally. Factors hypothesised to be associated with relapse and regression relate specifically to the nutrition and health status of the child on admission to, during and exit from treatment and treatment interventions, platforms and approaches as well as type of exit from treatment (e.g., before reaching recommended criteria). These factors influence whether children reach full recovery, and poorer nutritional and immunological status at exit from treatment are more proximate determinants of risk of severe wasting after treatment, although post-treatment interventions may modify risks. The evidence base for many of these factors is weak. Our framework can guide research to improve our understanding of risks of relapse and regression and how to prevent them and inform programmes on what data to collect to evaluate relapse. Implementation research is needed to operationalise results in programmes and reduce post-treatment severe wasting at scale.
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Affiliation(s)
| | - Amy Mayberry
- No Wasted Lives TeamAction Against Hunger UKLondonUK
| | - André Briend
- Center for Child Health ResearchTampere UniversityTampereFinland
- Department of Nutrition, Exercise and SportsUniversity of CopenhagenCopenhagenDenmark
| | - Mark Manary
- Department of PediatricsWashington University in St. LouisSt. LouisMissouriUSA
- School of Public Health and Family Medicine, College of MedicineUniversity of MalawiBlantyreMalawi
| | - Polly Walker
- No Wasted Lives TeamAction Against Hunger UKLondonUK
| | - Heather Stobaugh
- Action Against Hunger USNew YorkNew YorkUSA
- Friedman School Friedman School of Nutrition Science and PolicyTufts UniversityBostonMassachusettsUSA
| | | | | | - Robert Black
- Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMarylandUSA
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Response to Malnutrition Treatment in Low Weight-for-Age Children: Secondary Analyses of Children 6-59 Months in the ComPAS Cluster Randomized Controlled Trial. Nutrients 2021; 13:nu13041054. [PMID: 33805040 PMCID: PMC8064102 DOI: 10.3390/nu13041054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/15/2021] [Accepted: 03/19/2021] [Indexed: 11/16/2022] Open
Abstract
Weight-for-age z-score (WAZ) is not currently an admission criterion to therapeutic feeding programs, and children with low WAZ at high risk of mortality may not be admitted. We conducted a secondary analysis of RCT data to assess response to treatment according to WAZ and mid-upper arm circumference (MUAC) and type of feeding protocol given: a simplified, combined protocol for severe and moderate acute malnutrition (SAM and MAM) vs. standard care that treats SAM and MAM, separately. Children with a moderately low MUAC (11.5–12.5 cm) and a severely low WAZ (<−3) respond similarly to treatment in terms of both weight and MUAC gain on either 2092 kJ (500 kcal)/day of therapeutic or supplementary food. Children with a severely low MUAC (<11.5 cm), with/without a severely low WAZ (<−3), have similar recovery with the combined protocol or standard treatment, though WAZ gain may be slower in the combined protocol. A limitation is this analysis was not powered for these sub-groups specifically. Adding WAZ < −3 as an admission criterion for therapeutic feeding programs admitting children with MUAC and/or oedema may help programs target high-risk children who can benefit from treatment. Future work should evaluate the optimal treatment protocol for children with a MUAC < 11.5 and/or WAZ < −3.0.
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26
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Guesdon B, Couture A, Lesieur E, Bilukha O. "No weight for height" case detection strategies for therapeutic feeding programs: sensitivity to acute malnutrition and target composition based on representative surveys in humanitarian settings. BMC Nutr 2021; 7:3. [PMID: 33526090 PMCID: PMC7850713 DOI: 10.1186/s40795-021-00406-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 01/12/2021] [Indexed: 11/30/2022] Open
Abstract
Background One newly proposed approach to determining eligibility of children aged 6–59 months for therapeutic feeding programs (TFPs) is to use mid-upper arm circumference (MUAC) < 115 mm, bilateral oedema or Weight-for-Age Z-score (WAZ) < − 3 as admission criteria (MUAC+SWAZ). We explored potential consequences of this approach on the eligibility for treatment, as compared with the existing WHO normative guidance. We also compared sensitivity and specificity parameters of this approach for detecting wasted children to the previously described “Expanded MUAC” approach. Methods We analyzed data from 558 population representative cross-sectional cluster surveys conducted since 2007. We retrieved all children classified as severe acute malnutrition (SAM), moderate acute malnutrition (MAM), and those who are both wasted and stunted (WA + ST), and calculated proportions of previously eligible children who would now be excluded from treatment, as well as proportions of non-malnourished children among those who would become eligible. We also analyzed the expected changes in the number and demographics (sex, age) of the selected populations of children according to the different admission approaches. Results Both MUAC+SWAZ and Expanded MUAC case detection approaches substantially increase the sensitivity in detecting SAM, as compared to an approach which restricts detection of SAM cases to MUAC< 115 mm and oedema. Improved sensitivity however is attained at the expense of specificity and would require a very large increase of the size of TFPs, while still missing a non-negligible proportion (20–25%) of the SAM caseload. While our results confirm the sensitivity of the MUAC+SWAZ case detection approach in detecting WA + ST (over 80%), they show, on the other hand, that about half of the additional target detected by using SWAZ criterion will be neither SAM nor WA + ST. Conclusions These results suggest that recently promoted approaches to case detection inflate TFPs’ targets through the allocation of treatment to large numbers of children who have not been shown to require this type of support, including a significant proportion of non-acutely malnourished children in the MUAC+SWAZ approach. Considering the scarcity of resources for the implementation of TFPs, the rationale of abandoning the use of WHZ and of these alternative case detection strategies need to be critically reviewed.
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Affiliation(s)
- Benjamin Guesdon
- Action Contre La Faim - France, 14-16 Boulevard Douaumont, 75854, Paris, France.
| | - Alexia Couture
- Emergency Response and Recovery Branch, Division of Global Health Protection, Center for Global Health, Centers for Disease Control, 1600 Clifton Road, Atlanta, GA, 30329, USA
| | - Elise Lesieur
- Action Contre La Faim - France, 14-16 Boulevard Douaumont, 75854, Paris, France
| | - Oleg Bilukha
- Emergency Response and Recovery Branch, Division of Global Health Protection, Center for Global Health, Centers for Disease Control, 1600 Clifton Road, Atlanta, GA, 30329, USA
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27
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Stephenson KB, Agapova SE, Hendrixson DT, Koroma AS, Manary MJ. An Optimized Dose of Therapeutic Feeding Results in Noninferior Growth in Midupper Arm Circumference Compared with a Standard Dose in Children in Sierra Leone Recovering from Acute Malnutrition. Curr Dev Nutr 2021; 5:nzab007. [PMID: 33659773 PMCID: PMC7904386 DOI: 10.1093/cdn/nzab007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/25/2021] [Accepted: 01/28/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Ready-to-use therapeutic food (RUTF) given at 175 kcal/kg per day throughout severe acute malnutrition (SAM) treatment is recommended. Some treatment programs have diverged from this paradigm in 2 ways: reducing the supplemental food dose to 75 kcal/kg per day when midupper arm circumference (MUAC) is >11.4 cm or simplifying to a fixed-dose regimen. OBJECTIVE The objective was to determine if transitioning to an optimized, fixed-dose supplementary feeding regimen during SAM treatment when MUAC is >11.4 cm would result in noninferior gain in MUAC compared with standard treatment. METHODS Using data from 2 clinical trials conducted in Sierra Leone, a retrospective dual-cohort study was performed. The 2 cohorts included children with SAM who had improved to meet criteria for moderate acute malnutrition (MAM). The standard dose cohort continued to receive weight-based RUTF at 175 kcal/kg per day, while the optimized dose cohort received fixed-dose, 500 kcal/d of supplementary feeding. The primary outcome was a noninferiority margin of 1 mm of MUAC after 4 wk of treatment, while secondary outcomes included rate of anthropometric changes as well as time-to-relapse to SAM or death. RESULTS MUAC after 4 wk was noninferior (Δ: -0.1 mm; 95% CI: -0.05, 0.03; inferiority rejected P = 0.008). Rates of weight gain and MUAC gain were the same in the optimized-dose and standard-dose groups, whereas the rate of length gain was slower in the optimized-dose cohort. Time-to-relapse to SAM or death was not different (HR: 1.05; P = 0.71). CONCLUSIONS This study supports the practice of treating children with SAM who have recovered to meet criteria for MAM with a reduced and fixed-dose regimen of RUTF. The results also raise the question of whether this strategy might adversely impact linear growth during SAM treatment.
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Affiliation(s)
| | - Sophia E Agapova
- Department of Pediatrics, Washington University, St. Louis, MO, USA
| | | | - Aminata Shamit Koroma
- Ministry of Health and Sanitation, The Republic of Sierra Leone, Freetown, Sierra Leone
| | - Mark J Manary
- Department of Pediatrics, Washington University, St. Louis, MO, USA
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Cazes C, Phelan K, Hubert V, Alitanou R, Boubacar H, Izie Bozama L, Tshibangu Sakubu G, Beuscart A, Yao C, Gabillard D, Kinda M, Augier A, Anglaret X, Shepherd S, Becquet R. Simplifying and optimising management of acute malnutrition in children aged 6 to 59 months: study protocol for a community-based individually randomised controlled trial in Kasaï, Democratic Republic of Congo. BMJ Open 2020; 10:e041213. [PMID: 33268424 PMCID: PMC7713214 DOI: 10.1136/bmjopen-2020-041213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Acute malnutrition (AM) is a continuum condition, arbitrarily divided into moderate and severe AM (SAM) categories, funded and managed in separate programmes under different protocols. Optimising acute MAlnutrition (OptiMA) treatment aims to simplify and optimise AM management by treating children with mid-upper arm circumference (MUAC) <125 mm or oedema with one product-ready-to-use therapeutic food-at a gradually tapered dose. Our main objective was to compare the OptiMA strategy with the standard nutritional protocol in children 6-59 months presenting with MUAC <125 mm or oedema without additional complications, as well as in children classified as uncomplicated SAM (ie, MUAC <115 mm or weight-for-height Z-score (WHZ) <-3 or with oedema). METHODS AND ANALYSIS This study was a non-inferiority, individually randomised controlled clinical trial conducted at community level in the Democratic Republic of Congo. Children 6-59 months presenting with MUAC <125 mm or WHZ <-3 or with bipedal oedema and without medical complication were included after signed informed consent in outpatient health facilities. All participants were followed for 6 months. Success in both arms was defined at 6 months post inclusion as being alive, not acutely malnourished per the definition applied at inclusion and without an additional episode of AM throughout the 6-month observation period. Recovery among children with uncomplicated SAM was the main secondary outcome. For the primary objective, 890 participants were needed, and 480 children with SAM were needed for the main secondary objective. We will perform non-inferiority analyses in per-protocol and intention-to-treat basis for both outcomes. ETHICS AND DISSEMINATION Ethics approvals were obtained from the National Health Ethics Committee of the Democratic Republic of Congo and from the Ethics Evaluation Committee of Inserm, the French National Institute for Health and Medical Research (Paris, France). We will submit results for publication to a peer-reviewed journal and disseminate findings in international and national conferences and meetings. TRIAL REGISTRATION NUMBER NCT03751475. Registered 19 September 2018, https://clinicaltrials.gov/ct2/show/NCT03751475.
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Affiliation(s)
- Cécile Cazes
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, Bordeaux, France
| | - Kevin Phelan
- The Alliance for International Medical Action (ALIMA), Paris, France
| | - Victoire Hubert
- The Alliance for International Medical Action (ALIMA), Kamuesha, Democratic Republic of Congo
| | - Rodrigue Alitanou
- The Alliance for International Medical Action (ALIMA), Kamuesha, Democratic Republic of Congo
| | - Harouna Boubacar
- The Alliance for International Medical Action (ALIMA), Kamuesha, Democratic Republic of Congo
| | - Liévin Izie Bozama
- National Nutrition Programme (PRONANUT), Ministry of Health, Kinshasa, Democratic Republic of Congo
| | - Gilbert Tshibangu Sakubu
- Kamuesha Health Zone in the Kasaï Province, Ministry of Health, Kamuesha, Democratic Republic of Congo
| | - Aurélie Beuscart
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, Bordeaux, France
| | - Cyrille Yao
- PACCI Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Delphine Gabillard
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, Bordeaux, France
| | - Moumouni Kinda
- The Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Augustin Augier
- The Alliance for International Medical Action (ALIMA), Paris, France
| | - Xavier Anglaret
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, Bordeaux, France
| | - Susan Shepherd
- The Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Renaud Becquet
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, Bordeaux, France
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Bailey J, Opondo C, Lelijveld N, Marron B, Onyo P, Musyoki EN, Adongo SW, Manary M, Briend A, Kerac M. 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. PLoS Med 2020; 17:e1003192. [PMID: 32645109 PMCID: PMC7347103 DOI: 10.1371/journal.pmed.1003192] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 06/09/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND 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. METHODS AND FINDINGS 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. CONCLUSIONS 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). TRIAL REGISTRATION The trial is registered at ISRCTN, trial number ISRCTN30393230.
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Affiliation(s)
- Jeanette Bailey
- International Rescue Committee, New York, New York, United States of America
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Bethany Marron
- International Rescue Committee, New York, New York, United States of America
| | | | | | | | - Mark Manary
- Department of Pediatrics, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - André Briend
- Department of International Health, University of Tampere, Tampere, Finland
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Marko Kerac
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre for Maternal, Adolescent, Reproductive, & Child Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Chase RP, Kerac M, Grant A, Manary M, Briend A, Opondo C, Bailey J. Acute malnutrition recovery energy requirements based on mid-upper arm circumference: Secondary analysis of feeding program data from 5 countries, Combined Protocol for Acute Malnutrition Study (ComPAS) Stage 1. PLoS One 2020; 15:e0230452. [PMID: 32492023 PMCID: PMC7269364 DOI: 10.1371/journal.pone.0230452] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 03/01/2020] [Indexed: 01/31/2023] Open
Abstract
Background Severe and moderate acute malnutrition (SAM and MAM) are currently treated with different food products in separate treatment programs. The development of a unified and simplified treatment protocol using a single food product aims to increase treatment program efficiency and effectiveness. This study, the first stage of the ComPAS trial, sought to assess rate of growth and energy requirements among children recovering from acute malnutrition in order to design a simplified, MUAC-based dosage protocol. Methods We obtained secondary data from patient cards of children aged 6–59 months recovering from SAM in outpatient therapeutic feeding programs (TFPs) and from MAM in supplementary feeding programs (SFPs) in five countries in Africa and Asia. We used local polynomial smoothing to assess changes in MUAC and proportional weight gain between clinic visits and assessed their normalized differences for a non-zero linear trend. We estimated energy needs to meet or exceed the growth observed in 95% of visits. Results This analysis used data from 5518 patients representing 33942 visits. Growth trends in MUAC and proportional weight gain were not significantly different, each lower at higher MUAC values: MUAC growth averaged 2mm/week at lower MUACs (100 to <110mm) and 1mm/week at higher MUACs (120mm to <125mm); and proportional weight gain declined from 3.9g/kg/day to 2.4g/kg/day across the same MUAC values. In 95% of visits by children with a MUAC 100mm to <125mm who were successfully treated, energy needs could be met or exceeded with 1,000 kilocalories a day. Conclusion Two 92g sachets of Ready-to-Use Therapeutic Food (RUTF) (1,000kcal total) is proposed to meet the estimated total energy requirements of children with a MUAC 100mm to <115mm, and one 92g sachet of RUTF (500kcal) is proposed to meet half the energy requirements of children with a MUAC of 115 to <125mm. A simplified, combined protocol may enable a more holistic continuum of care, potentially contributing to increased coverage for children suffering from acute malnutrition.
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Affiliation(s)
- Rachel P. Chase
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail:
| | - Marko Kerac
- Department of Population Health & Centre for Maternal, Adolescent and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, England, United Kingdom
| | - Angeline Grant
- Action Against Hunger-USA, New York, New York, United States of America
| | - Mark Manary
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, United States of America
| | - André Briend
- University of Tampere, University of Tampere School of Medicine, Center for Child Health Research, Tampere, Finland
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, England, United Kingdom
| | - Jeanette Bailey
- Department of Population Health & Centre for Maternal, Adolescent and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, England, United Kingdom
- International Rescue Committee, New York, New York, United States of America
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